"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

January 14, 2018

Medical students are being urged to help relieve the NHS winter crisis because hospitals are so short-staffed they are struggling to cope with the surge in patients, the Guardian can reveal.

Despite their lack of experience, undergraduates are being asked to volunteer in A&E units and on wards reeling under the weight of extra demand caused by the cold weather, an outbreak of flu and people suffering serious breathing problems.

They have been told to expect to fit cannulas – the tubes inserted so patients can receive medication – and take blood, work usually done by nurses or qualified doctors.

The British Medical Association said that asking students who had not qualified in medicine to assist with, in some cases, severely ill patients was “a desperate measure” that could put patients at risk and exploit undergraduates who agreed to help.

The disclosure led to warnings that hospitals could face legal difficulties if students made mistakes and concern that their presence on wards could disguise the depth of NHS understaffing.

Medical schools are asking fourth- and fifth-year students for urgent assistance at “hard-pressed” nearby hospitals and GP surgeries, according to emails obtained by the Guardian.

Dr Andrew Hassell, the head of Keele University’s medical school, wrote to students recently to enlist support in tackling the NHS’s “national crisis”.

“We’re sure you don’t need us to tell you about the extraordinary -situation the whole of the NHS is facing this winter,” wrote Hassell, who is also a senior figure at the NHS trust that runs hospitals in Stoke and Stafford.

“As the medical school for this area we think we should be doing whatever we can to support local services while maintaining student learning. We are sure you will want to be part of our collective effort at this time of national crisis,” he said in the email, sent last week. He added that he had already contacted the medical director at his own trust and at the Shrewsbury and Telford Hospital NHS Trust “to ask them to let us know if there’s anything we can do to help”. \

Hassell told students: “Do volunteer to help in any way possible, providing it’s within your competence. This applies to students in hospitals and in GP [general practice]”.

On 4 January, two days after the seriousness of the winter crisis led NHS bosses to cancel tens of thousands of operations, medical undergraduates at Liverpool University received a similar email. It told them “the NHS is currently facing unprecedented pressures, particularly in the emergency departments and acute wards”, adding: “During this difficult time it is likely placements may ask student doctors to assist in the acute areas where there is most pressure.”

And this is going on in the United Kingdom, though a recent Commonwealth Fund assessment puts the UK's overall healthcare-system ranking at #1, versus #11 for the US and #9 for Canada. That does not bode well for surge capacity in even the richest countries.

January 11, 2018

Teaching unions are warning of an “epidemic of stress” as research revealed that 3,750 teachers were signed off on longterm sick leave last year because of pressure of work, anxiety and mental illness.

Figures obtained through a mass freedom of information request show a 5% rise on the year before, revealing that one in 83 teachers spent more than a month off work in 2016-17.

Altogether 1.3 million days have been taken off by teachers for stress and mental health reasons in the last four years, including around 312,000 in 2016-17, the figures compiled by the Liberal Democrats show.

Dr Mary Bousted, joint general secretary of the National Education Union, warned of an “epidemic of stress”.

“Teachers work more unpaid overtime than any other profession,” she said. “Classroom teachers routinely work 55 hours or over a week. School leaders routinely work over 60 hours a week.

“And it is not just the amount of work. It is the pressures of a punitive and non-productive accountability system.”

Bousted said the number of ways in which a school could be deemed to be failing had ballooned in recent years – and there was relentless pressure to demonstrate even minute progress. She said that often came at the cost of “real improvements”, describing English children as some of the “most over-assessed in the modern world”.

She added that schools had been bombarded with constant changes to the curriculum and assessment regimes. “It has been a relentless policy onslaught which has left teachers rocking from stress and exhaustion.”

Bousted warned that the problem had contributed to a steep decline in teacher training applications, despite expensive advertising campaigns.

“You’ve got half a million teachers in England and Wales. Everyone is someone’s mother or father, son or daughter, aunt or friend, and they see the stress,” she said. “So you can’t talk up the profession when people see the reality.”

November 15, 2017

The Conservatives have been accused of “economic murder” for austerity policies which a new study suggests have caused 120,000 deaths.

The paper found that there were 45,000 more deaths in the first four years of Tory-led efficiencies than would have been expected if funding had stayed at pre-election levels.

On this trajectory that could rise to nearly 200,000 excess deaths by the end of 2020, even with the extra funding that has been earmarked for public sector services this year.

Real terms funding for health and social care fell under the Conservative-led Coalition Government in 2010, and the researchers conclude this “may have produced” the substantial increase in deaths.

The paper identified that mortality rates in the UK had declined steadily from 2001 to 2010, but this reversed sharply with the death rate growing again after austerity came in.

From this reversal the authors identified that 45,368 extra deaths occurred between 2010 and 2014, than would have been expected, although it stops short of calling them "avoidable".

Based on those trends it predicted the next five years - from 2015 to 2020 - would account for 152,141 deaths - 100 a day - findings which one of the authors likened to “economic murder”.

The Government began relaxing austerity measures this year announcing the end of its cap on public sector pay rises and announcing an extra £1.3bn for social care in the Spring Budget.

Over three years the additional funding for social care is expected to reach £2bn, which Labour leader Jeremy Corbyn said was “patching up a small part of the damage” wrought by £4.6bn cuts.

The study, published in BMJ Open today, estimated that to return death rates to their pre-2010 levels spending would need to increase by £25.3bn.

The Department of Health said “firm conclusions” cannot be drawn from this work, and independent academics warned the funding figures were “speculative”.

However local councils who have been struggling to fund care with slashed budgets urged the Government to consider the research seriously.

This is not a surprise breakthrough. The link between income and health has been understood for a very long time; the effect of "austerity" is to widen the gap between rich and poor—and to shorten the lives of the poor. I discussed the issue in a 2013 Tyee review of a book titled Why Austerity Kills.

October 10, 2017

Athens – A mental health emergency for asylum seekers is unfolding on the Greek islands, largely created by poor living conditions, neglect and violence, according to a report by Médecins Sans Frontières (MSF).

MSF calls on the European Union (EU) and authorities in Greece to stop inflicting additional suffering on people who are already traumatised, and to immediately relocate all asylum seekers from the islands to the Greek mainland, where they have a greater chance of accessing proper accommodation and health services.

“These people have survived bombing, extreme violence and traumatic events in their home countries or on the road to Europe,” says Jayne Grimes, manager of MSF’s mental health activities on the island of Samos. “But shamefully it’s what they face on the Greek islands that leads them into despair, hopele ssness and self-harm. Every day our teams treat patients who tell us that they would prefer to have died in their country than be trapped here.”

Between June and September, an average of six to seven new patients per week arrived at MSF’s clinic on Lesbos in acute need of mental health consultations following suicide attempts, incidents of self-harm, or psychotic episodes. A 50 percent increase in the number of patients to our clinic compared to the previous trimester was also reported.

Among the factors aggravating people’s mental distress was violence experienced either on the journey or in Greece, according to many of MSF’s patients. A survey conducted by MSF and Epicentre in Samos in late 2016 and early 2017 reported that close to half of those surveyed had experienced violence while passing through Turkey, and close to a quarter had experienced violence since arriving in Greece.

The survey also found that people who arrived on Samos after the EU-Turkey deal was signed in March 2016 reported more violence in Turkey and Greece than those who arrived before the deal came into force. Between 50 per cent and 70 per cent of that violence was allegedly committed by state authorities.

MSF calls on the Greek authorities to immediately relocate asylum seekers to the Greek mainland, and as an urgent measure to step up the provision of mental healthcare, including psychiatric care and other crucial services, to meet the needs of these extremely traumatised men, women and children.

The streets are full of garbage, rubble, and plant material, which could cause serious health problems in the population when only 20 hospitals are functioning across the island. Many aren't functioning to capacity owing to the lack of electricity.

The tail end of a disaster is usually less interesting but more damaging. Mexican media are reporting thousands of homes and other buildings that are either total write-offs or seriously damaged. Rehousing their previous residents is likely to take months, while the residents endure stress and mental health problems.

Similarly, over 75,000 Indonesians have been evacuated from around Mount Agung. Some old-timers recall the 1963 Agung eruption; their evacuation camps were crowded, unsanitary, and boring, and the new ones are much the same.

Public health problems are going to increase in all the hurricane-hit regions from Houston to Barbuda. Rats will proliferate; that make leptospirosis more likely. Mosquito-borne diseases like Zika, chikungunya, and dengue are predictable hazards, and waterborne diseases like diarrhea and even cholera are likely.

None of these problems are likely to gain much attention in the North American media, and without that attention the US authorities are unlikely to dedicate sufficient resources to deal with them.

The recent policy debates about DACA have centered on the program’s economic consequences, while its substantial public health benefits have been less discussed. A recent quasi-experimental study compared changes in mental and physical health outcomes among persons who were eligible for DACA with those of a similar group of noncitizens who did not meet at least one of the eligibility criteria.

The study showed that rates of moderate or severe psychological distress in the DACA-eligible group fell by nearly 40% relative to rates in the DACA-ineligible group after DACA’s passage. Similarly, descriptive studies of DACA beneficiaries have revealed remarkable improvements in psychological well-being after the program’s implementation.

The most recent contribution to this literature has shown, using data on Emergency Medicaid beneficiaries in the state of Oregon, that the mental health benefits of DACA extended across generations: among the children of DACA-eligible mothers — the majority of whom are U.S. citizens by birth — rates of adjustment and anxiety disorders fell by more than half after DACA was implemented.

The evidence clearly indicates that rescinding DACA will have profound adverse population-level effects on mental health. Moreover, these effects will most likely be potentiated by the broader hostile political climate surrounding immigration. In addition to rescinding DACA, other elements of the Trump administration’s immigration platform include enhancing authority and providing means to implement existing immigration policies, banning or reducing immigration by specific population groups, and strengthening border security. These policies could further increase the risk of deportation for Dreamers and their family members, which could reinforce any adverse mental health consequences of DACA’s termination. That DACA has been repealed in the context of the increasingly divisive and nativist rhetoric that has infected many ongoing public conversations — which itself may have independent adverse effects on mental health4 — will only exacerbate its negative health effects.

The potential mental health fallout from DACA’s termination will be immensely challenging to address through our formal health care and public health systems because it is likely to be a silent and unseen problem. Removing legal protections from deportation will reduce the likelihood that Dreamers will seek help from physicians, nurses, educators, or social workers, given the very realistic fears of coming under scrutiny by immigration authorities. Such fears and isolation will make it difficult to deploy mental health treatment and public mental health resources where they will be needed most.

These effects are likely to manifest even in states that provide more generous benefits to undocumented immigrants (e.g., Massachusetts and California) and in “sanctuary cities,” because federal authorities have stepped up raids to identify and deport undocumented immigrants in these areas. Moreover, Dreamers who do seek help may have fewer avenues for obtaining it if the loss of work permits leads to unemployment (or forced withdrawal from school due to loss of financial aid) and subsequent loss of health insurance.

September 12, 2017

When major disasters like Hurricanes Harvey and Irma hit, the first priority is to keep people safe. This process can involve dramatic evacuations, rescues and searches.

However, after the initial emergency passes, a much longer process of recovering and rebuilding begins. For individuals, families and communities, this can last months or even years. This work often begins at the same time as the national media starts packing up and public attention shifts to the next major news story.

At the University of Missouri’s Disaster and Community Crisis Center, we study disaster recovery, rebuilding and resilience. Much of our research shows that natural disasters can have a meaningful impact on survivors’ mental and behavioral health. These issues typically emerge as people try to recover and move forward after the devastation.

Health and disasters

Immediately after a natural disaster, it’s normal to experience fear, anxiety, sadness or shock. However, if these symptoms continue for weeks to months following the event, they may indicate a more serious psychological issue.

The disaster mental health problem most commonly studied by psychologists and psychiatrists is post-traumatic stress disorder, which can occur after frightening events that threaten one’s own life and the lives of family and friends.

Following a disaster, people might lose their jobs or be displaced from their homes. This can contribute to depression, particularly as survivors attempt to cope with loss related to the disaster. It’s not easy to lose sentimental possessions or face economic uncertainties. People facing these challenges can feel hopeless or in despair.

Substance use can increase following disasters, but usually only for individuals who already used tobacco, alcohol or drugs before the disaster. In a study of Hurricane Katrina survivors who had been displaced to Houston, Texas, approximately one-third reported increasing their tobacco, alcohol and marijuana use after the storm.

There’s also evidence that domestic violence increases in communities experiencing a disaster. After Hurricane Katrina, another study found that, among women in Mississippi who were displaced from their homes, domestic violence rates increased dramatically. Perpetrators may feel a loss of control following the disaster and turn to abusive behavior to try to gain that control back in their personal relationships.

Disaster recovery

While many disaster survivors show resilience, studies have shown mental and behavioral health issues cropping up weeks, months and even years after a disaster.

Rebuilding can be a long process, with a series of ups and downs. Survivors may bounce back after a few months, or they may experience ongoing stressors, such as financial issues or problems finding permanent housing. Disaster anniversaries or other reminders – like a heavy rainstorm months after a hurricane – may also trigger reactions.

In addition, early disaster recovery efforts often focus on physical reconstruction. Psychological recovery may end up on the back burner.

A world expert in health outcomes has urged the UK government to launch an inquiry into why life expectancy rates in Britain have stalled.

Sir Michael Marmot, the author of a government-ordered report on health inequality, said the country risked becoming the “sick man and woman of Europe”.

He compared progress in Britain with that of other European nations, many of which have longer and extending life expectancies.

His analysis found that according to the EU statistics body Eurostat, the UK is falling further behind, with growth in female life expectancy at birth the worst in Europe and male growth the second worst.

Marmot, director of the Institute of Health Equity at University College London, wrote in the Times: “Were this to keep up, we would soon become the sick man and woman of Europe. This is a new and worrying trend.”

In Britain, the female life expectancy at birth is 83, below the EU average, while for men it is slightly above the average at 79.

Marmot has written to Jeremy Hunt urging him to set up an inquiry into the slowdown, saying that “austerity is an obvious candidate”.

Marmot's own research helped to identify a striking trend in the 1970s and 80s: UK life expectancies in the 1960s were well ahead of those in Japan. But with the accession of the Thatcher government, UK life expectancies began to level off while the Japanese forged ahead.

Japan's income and wealth gaps are far narrower than those in the UK, not to mention the US and Canada. Life expectancy demonstrates the consequences of plutocracy. Many of us are literally dying for the rich.

Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP.

Methods:

An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures.

Results:

There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure.

Interpretation:

The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.

August 29, 2017

Here in Houston, a patient shivering in August is never a good sign. On Monday, as Hurricane Harvey brought its third day of catastrophic rain to southeastern Texas, a steady procession of refugees sloshed into the George R. Brown Convention Center, the city’s largest emergency shelter. They were cold and wet. Many couldn’t stop shaking.

I had been scheduled to work a shift at Ben Taub Hospital, where I am an internist, but flooding there had forced a partial shutdown, so I spent the afternoon volunteering for the Red Cross instead, treating patients in one of the convention center’s large halls.

In the rush to evacuate—on foot, by boat, in rescue helicopters—some people had left behind seizure medication, asthma inhalers, insulin. Dialysis patients didn’t know how to get to their treatment centers, if the centers were even still open. One woman said that her cardiologist had told her that if she didn’t take her blood thinner every day, she might have a heart attack. Was her life in danger?

As is often the case in the early stages of a disaster, demand quickly outstripped supply. Only a few doctors had made it to the convention center, which was already nearing its five-thousand-person capacity, and the makeshift pharmacy could dispense only over-the-counter medicines such as ibuprofen and children’s Tylenol. No antibiotics, and certainly no blood thinners, were available—how could they be, with the roads so inundated, and in such a short time?

One patient I saw had spent a full day in the rising waters. The triage team had measured her temperature at ninety-three degrees Fahrenheit, qualifying her as hypothermic. My first instinct was to heat her with a device called a Bair Hugger, an inflatable warming blanket commonly used in hospitals. When I asked one of the E.M.T.s whether he might have one, he responded as generously as he could. “We’re hoping to get more towels,” he said.

I remember, early in my career, finding the word “reassure” listed as a possible response on many multiple-choice tests, including for my medical license, and feeling put off by it. To my novice ears, “reassure” sounded like “do nothing.” But, over the years, I’ve learned that understanding why a patient might be scared and targeting that fear with your words can serve as a powerful remedy.

We didn’t have much in the way of equipment or medications at the convention center, but we could reassure those who were more wet and frightened than sick. My experiences at Ben Taub, a safety-net hospital that specializes in the care of poor and uninsured people, helped me in this regard. I could tell the woman who was nervous about her blood thinners that some of my patients had gone without the drugs for a month or more. I could tell the diabetics that staying well hydrated was one of the best ways to keep their high blood sugar in check, because I had seen so many patients who didn’t have money for insulin.

The extreme circumstances, I said, made their missing a dose or two O.K. As more evacuees arrived, so did more doctors and nurses and pharmacists—not such a surprise, since medicine is to Houston what finance is to lower Manhattan.

The Texas Medical Center is the largest medical district in the world, home to such renowned institutions as the M. D. Anderson Cancer Center and Texas Children’s Hospital. Before I knew it, a refrigerator stocked with insulin had been installed by the large partition that separated the medical area from a jumbo TV. (Crimson bands of rain swept across the Doppler radar, again and again.)

Someone organized a row of chairs for patients whose blood sugar was too high for hydration alone; they received I.V. fluids and a rescuing shot of insulin. At one point, a box full of sandwiches arrived, and I asked an E.M.T. whether I could give one to my hypothermic patient, since eating revs up one’s metabolism. “We’re all sharing here,” he said.